Annals of hepato-biliary-pancreatic surgery最新文献

Backgrounds/aims: Balancing surgical risks and benefits is crucial for managing non-functional pancreatic neuroendocrine tumors (NF-PNETs). Despite high postoperative pancreatic fistula (POPF) rates, studies on postoperative complications of sporadic NF-PNETs are scarce. Thus, this study aimed to investigate postoperative complications and identify risk factors for POPF.

Methods: A retrospective review of 166 NF-PNET surgeries performed at Severance Hospital between February 2000 and August 2023 was conducted.

Results: Age > 65 years and higher American Society of Anesthesiology (ASA) grade were not significantly correlated with severe complications (odds ratio [OR]: 1.10, p = 0.871 and OR: 1.47, p = 0.491, respectively). Surgical procedures included enucleation (13.9%), distal pancreatectomy (50.0%), central pancreatectomy (4.8%), pancreaticoduodenectomy (PD) (26.5%), and total pancreatectomy (4.8%). Severe complications occurred in 12.05% of surgeries. The overall incidence of all POPFs including biochemical leaks was 53%, while clinically relevant POPF (grade B or C) occurred in 7.8% of patients. Logistic regression showed that PD (OR: 3.94, p = 0.092) tended to be risk factor for POPF and that diameter of the main pancreatic duct (MPD) ≤ 3 mm was a significant risk factor for POPF (OR: 0.22, p = 0.008). A pancreas thickness (PT)/MPD ratio > 4.47 on preoperative computed tomography predicted all POPFs in PD patients (OR: 11.70, p = 0.001).

Conclusions: Age and comorbidities had no significant impact on surgical outcomes. PD was associated with higher serious complications and POPF rates. The PT/MPD ratio is a valuable preoperative tool for predicting POPF risk in PD patients.

Backgrounds/aims: The 3-year mortality rate for hepatocellular carcinoma (HCC) in Indonesia was 94.4%. This underscores a significant health issue in Southeast Asia, particularly in Indonesia due to its large population. This study aimed to characterize the outcomes of liver resection for HCC at a National Referral Center in Indonesia.

Methods: Between 2010 and 2020, all patients with HCC undergoing liver resection were included as subjects. Variables collected included sex, age, hepatitis status, and tumor's characteristics. Mortality and survival were the primary outcomes of the study.

Results: Among seventy patients, the mortality rate was 71.4%, with a median overall survival of 19.0 months (95% confidence interval [95%CI]: 6.831.2). Thirty-one patients (44.3%) had extra-large HCC tumors (> 10 cm). Those with extra-large tumors had a lower median survival of 8.0 months. Child-Pugh B and Edmonson-Steiner grade 4 were associated with an increased mortality risk, with unadjusted hazard ratios (HRs) of 2.2 (95%CI: 1.14.3, p = 0.026) and 3.2 (95%CI: 1.37.7, p = 0.011), respectively. Multivariate analysis indicated that Child-Pugh class B significantly increased the risk of mortality, with an adjusted HR of 2.3 (95%CI: 1.05.2, p = 0.046).

Conclusions: While surgical resection is feasible for tumors of any size, most clinical features are not statistically significantly associated with survival outcomes. The prevalence of extra-large tumors among Indonesian HCC patients highlights the importance of early diagnosis and intervention. Surgical intervention at an earlier stage and with better grade tumors could potentially enhance survival outcomes.

Laparoscopic cholecystectomy (LC) is the gold standard for the treatment of symptomatic gallstones, acute cholecystitis, and acute gallstone pancreatitis. In recent years, the development and diffusion of robotic surgery have provided surgeons with the opportunity to apply this innovative approach to cholecystectomy, yielding interesting results. However, as with any new surgical technique, robotic cholecystectomy (RC) has met with skepticism within the surgical community. Beyond the understandable concerns regarding increased costs, some authors have claimed that RC is associated with a higher complication rate compared to LC. We reviewed the existing literature on this subject, discussing the limitations and strengths of the most significant publications and critically analyzing them. The analysis of the literature indicates that RC is safe and effective, with no definitive evidence of its inferiority compared to LC. Some of the published papers are of low quality and biased, even with significant sample sizes. Furthermore, we believe that comparing an established technique like LC with a new and not yet standardized one such as RC is somewhat illogical. RC represents a significant advance in minimally invasive surgery and should be viewed as an opportunity to familiarize oneself with the robotic device and to enhance the surgeon's skills in preparation for more complex robotic operations. The robotic approach can be beneficial in selected cases of cholecystectomy where fine dissection is required. With further reductions in costs, RC could become the future gold standard for benign gallbladder disorders.

Backgrounds/aims: Pancreatic texture is difficult to predict without palpation. Soft pancreatic texture is associated with increased post-operative complications, including postoperative pancreatic fistula (POPF), cardiac, and respiratory complications. We aimed to develop a calculator predicting pancreatic texture using patient factors and to illustrate complications from soft pancreatic texture following pancreaticoduodenectomy.

Methods: Data was collected from the 2016 to 2021 American College of Surgeons National Surgical Quality Improvement database including 17,706 pancreaticoduodenectomy cases. Patients were categorized into two cohorts based on pancreatic texture (9,686 hard, 8,020 soft). Multivariable modeling assessed the impact of patient factors on complications, mortality, and pancreatic texture. These preoperative factors were integrated into a risk calculator (preoperative soft pancreas risk score [PSPRS]) that predicts pancreatic texture.

Results: Patients with a soft pancreas had higher rates of postoperative complications compared to those with a hard pancreas (56.5% vs 42.2%; p < 0.001), particularly a threefold increase in POPF rate, and at least a twofold increase in rates of acute kidney injury, deep organ space infection, septic shock, and prolonged length of stay. Female sex (odds ratio [OR]: 1.14, confidence interval [CI]: 1.06-1.22, p < 0.001) and higher body mass index (OR: 1.12, CI: 1.09-1.16, p < 0.001) were independently associated with a soft pancreas. PSPRS ≥6 correctly identified >40% of patients preoperatively as having a hard pancreas (68.9% specificity).

Conclusions: A soft pancreas was independently associated with serious postoperative complications. Our results were integrated into a risk calculator predicting pancreatic texture from preoperative patient factors, potentially enhancing preoperative counseling and surgical decision-making.

Laparoscopic total pancreatectomy (LTP) is technically challenging and infrequently documented in the literature. In this paper, we present a new approach for performing fully LTP, a pancreatic tail-first approach with a counterclockwise technique, to accomplish total mesopancreas dissection and standard lymphadenectomy en bloc. Firstly, the tail and body of the pancreas without the spleen were dissected retrogradely, starting from the lower border of the body of pancreas and then from left to right. After that, a counterclockwise dissection of the tail and body of the pancreas was performed. The splenic artery and vein were divided at the terminal end of the pancreatic tail. The spleen was preserved. The entire body and tail of the pancreas were then pulled to the right side. This maneuver facilitated the isolation and dissection of arteries in the retropancreatic region more easily via laparoscopy, including the splenic artery, gastroduodenal artery, and supporting superior mesenteric artery first-approach. It also enabled total mesopancreas dissection. The inferior pancreaticoduodenal artery was resected last during this phase. The remainder of the dissection was like that of a laparoscopic pancreaticoduodenectomy with total mesopancreas dissection, involving two laparoscopic manual anastomoses. The operative time was 490 minutes and the total blood loss was 100 mL. Pathology revealed a low-grade intraductal papillary mucinous neoplasm extending from the head to the tail of the pancreas.

Robotic liver transplantation represents a cutting-edge technique that may surpass traditional open surgery. Nonetheless, it introduces unique anesthetic challenges, including extended pneumoperitoneum, restricted patient access, and a risk of undetected blood loss. This article describes an anesthetic approach and patient outcomes for the first four total robotic liver transplants performed at a tertiary university hospital in Portugal, along with inaugural procedures of their kind in Europe. We retrospectively analyzed surgical and anesthetic data from four patients who underwent total robotic liver transplantation from February to April 2024. Data encompassed clinical profile, preoperative assessment, surgical and anesthesia details, postoperative course, and outcomes. Patients' age ranged from 51 to 69 years. Their cirrhosis was primarily due to alcohol use, hepatitis C virus infection, hepatocellular carcinoma, or nonalcoholic steatohepatitis. General anesthesia was administered. Hemodynamic monitoring and goal-directed fluid therapy were conducted using a PiCCO system. Blood loss varied from 1,000 to 5,000 mL. Blood products were transfused as needed. All donor livers underwent hypothermic oxygenated machine perfusion before transplantation. After surgery, two patients were immediately extubated, while two required extended ventilation. Hospital stays ranged from 10 to 40 days. The 30-day survival rate was 100%. This initial case series affirmed the feasibility and safety of total robotic liver transplantation for carefully selected patients, yielding favorable short-term results. Anesthetic management can rely on proactive strategies, acute situational awareness, and effective multidisciplinary collaboration.

Backgrounds/aims: Irreversible electroporation (IRE) may have a potential application as either a "back-up therapy" or for margin accentuation during trial dissection of locally advanced pancreatic cancer (LAPC). The aim of this report was to describe our experience with IRE in terms of its potential applications mentioned above.

Methods: A clinical policy to use IRE in LAPC patients undergoing exploratory surgery after neoadjuvant therapy (NAT) was initiated in 2017. If resection was feasible, IRE was used for margin accentuation. If not, then IRE was undertaken as a "back-up therapy" of non-resectable tumor. Data on baseline characteristics, perioperative 90-day morbidity, recurrence-free survival (RFS) and overall survival (OS) were collected.

Results: IRE was successfully performed in 18 (95%) patients. IRE was abandoned in one case for technical reasons. Nine patients who were found to have an unresectable disease underwent IRE as a "back-up therapy" while the remaining patients received IRE for margin accentuation. Complications were recorded in 33% patients. There was no procedure-related mortality. In the group receiving IRE for margin accentuation, the median RFS was 10.0 months (range, 4.5-15.0 months). The median OS of our cohort was 22 months (range, 14.75-27.50 months).

Conclusions: This report shows that in patients with LAPC undergoing exploratory surgery following NAT, IRE seems technically feasible for margin accentuation or as a "back-up therapy". More data are needed to determine procedure-related morbidity, mortality, and any effects of IRE on cancer-related survival.

Backgrounds/aims: Endoscopic retrograde cholangiopancreatography (ERCP) combined with laparoscopic cholecystectomy (LC) remains the most common therapeutic strategy used for cholecystocholedocholithiasis (CCL). Recently, single-stage ERCP + LC has gained popularity for treating CCL due to patient satisfaction and financial considerations. In this study, we aimed to compare the feasibility and efficacy of the two variants of single-stage ERCP + LC (starting with ERCP followed by LC versus starting with LC followed by ERCP) for treatment of CCL.

Methods: A total of 115 patients who underwent single-stage ERCP + LC for CCL from January 2021 to December 2023 were enrolled in a retrospective comparative cohort study. These patients were divided into two groups: Group A (ERCP-first approach) and Group B (LC-first approach).

Results: Patients in Group A had a common bile duct clearance rate of 88.2%, which was comparable to the 95.7% observed in Group B (p = 0.163). The mean duration of the ERCP procedure was comparable between the two groups (43.3 ± 11.8 vs 39.5 ± 13.5 minutes; p = 0.112). However, the mean duration of the LC procedure was significantly longer in Group A than in Group B (41.2 ± 8.98 vs 37.2 ± 12.2 minutes; p = 0.045). The mean total operative time for the combined ERCP + LC was significantly longer in Group A compared to Group B (81.9 ± 16.7 vs 75.1 ± 19.3 minutes; p = 0.046). Post-ERCP pancreatitis occurred in 4 patients in Group A and in 2 patients in Group B (p = 0.701).

Conclusions: Both LC-1st approach and ERCP-1st approach are feasible and highly effective for treating CCL through single-stage ERCP + LC. However, the LC-1st approach has the advantage of a shorter operative time.